Final Report: Everyone Failed when Grenfell Tower Burned

Seven years after the deadly fire at London’s high-rise Grenfell Tower, the final report concludes that lawmakers, housing management, architect and engineers, contractors, material manufacturers, testing institutes, certification bodies, and emergency services all failed miserably. This failure claimed the lives of 72 people.

The fire was the culmination of decades of neglect by both the government, authorities, and the construction industry. This is detailed in the final report on the fatal fire that broke out in the 23-story social housing complex Grenfell Tower in London on June 14, 2017.

Incompetence from all parties involved, lies, cover-ups, and delays were all contributing factors to the disaster. Furthermore, all 72 deaths could have been avoided. This is the conclusion of the extensive report, which has taken so long due to the case’s enormous complexity.

Facade materials bear the most blame

The high-rise building received a new facade system in 2015-2016, including cladding of so-called ACM panels consisting of two thin sheets of aluminum with a core of combustible polyethylene (PE). The fire created a chimney effect in the cavity between the ACM panels and the insulation, fueled by the combustible materials. This led to rapid fire spread on the facade.

The combustible materials should never have been used on a building higher than 18 meters, which is the limit set by British guidelines. However, according to the report, the manufacturers of the facade components are the biggest culprits. Fire tests were manipulated, and outdated product certificates were used despite changes in the product. Additionally, the manufacturer of the facade panels failed to disclose the significantly higher fire risk associated with mounting the panels in cassette form versus fastening them with rivets. One material manufacturer is even believed to have deliberately concealed safety risks, while others are said to have misled the market.

Certification bodies are also heavily criticized for failing to ensure that the product certificates’ declarations were accurate and based on test documentation.

Incompetent advisors

Accusations of incompetence are prevalent throughout the lengthy report. Both advisors and contractors are criticized for lacking competence in current fire regulations and for failing to understand both the nature and extent of their responsibilities. For example, everyone involved in selecting materials for the facade system believed that the responsibility for assessing whether the materials were appropriate and safe lay with someone else.

– No one had the competence to understand the consequences of using building materials outside their intended scope, says Anders Dragsted, Head of Advanced Fire Engineering at DBI. He is supported by Brian V. Jensen, Construction Market Lead at DBI:

– When you build with robust materials and follow traditional construction methods, it is not considered a complex building in fire safety terms. This is true even when renovating the facade of a high-rise building like Grenfell Tower. Therefore, no enhanced competence requirements are placed on the responsible fire safety engineers and building inspectors, which means that such high-rise projects can end up being supervised by advisors without formal competence requirements.

Authorities ignored fire hazards

The government and national authorities also receive strong criticism in the report. Even after a high-rise facade fire in 1991 and countless calls to introduce stricter regulations on facade systems and the use of combustible materials, nothing was done within British law. On the contrary, the Conservative/Liberal government at the time was so intent on cutting regulations that safety issues were either “ignored or postponed”, according to the report. As a result, there had been no serious update to the UK’s building regulations for many years.

At the same time, the responsible housing management remained inactive, ignoring the fire safety concerns repeatedly raised by residents. Although it was recommended as early as 2009 that a fire strategy be prepared for the building, especially for vulnerable residents, no approved strategy was in place when the building burned in 2017.

– It also reflects a social bias. Would the same thing have happened in one of London’s luxury buildings? asks Anders Dragsted.

Emergency Services unprepared for the task

The London Fire Brigade is also heavily criticized in the report. The emergency services had not learned from previous high-rise fires and had not undergone the necessary training to handle such fires. Additionally, they lacked sufficient knowledge of the fire risks posed by combustible materials, and had failed to share knowledge internally about modern materials and methods of construction. Further criticism is directed at the organization and management within the London Fire Brigade.

The building’s evacuation strategy also proved fatal for many residents. The so-called ‘stay put’ strategy meant that in the event of a fire, residents were advised to remain in their apartments and wait for help from the emergency services. However, they did not account for the overwhelming number of emergency calls from residents in distress, which overloaded control room staff and made the response inefficient. It wasn’t until 1.5 hours after the initial call that the tactic changed, and residents were told to leave their apartments. By that time, it was too late, because the stairwell was filled with smoke due to a malfunctioning ventilation system.

The report concludes that the fire services lacked a strategy to evacuate the building after they lost control of the situation, and they had not anticipated a fire of this scale, leaving them unprepared.

– As an emergency service, it can be difficult to be fully equipped for a fire like the one at Grenfell Tower. But you shouldn’t have to be if buildings are designed and constructed with sufficient fire safety measures – and are properly maintained. If that had been done, this incident could have been avoided, says Anders Dragsted.

Recommendations for improvements

The report also contains a wide range of recommendations for improving fire safety in high-rise buildings.

– Among other things, it is recommended to establish a system comparable to the Danish certification scheme, where there is much greater focus on documentation and oversight of construction, as well as the competencies of fire safety engineers. Additionally, it calls for increased transparency regarding product documentation, both in terms of product certificates and the supporting documentation, says Anders Dragsted, who continues:

– Moreover, the education level of fire safety engineers must be raised, and the emergency services should receive more training. A fire strategy should be developed for all buildings, with evacuation as part of the strategy, especially concerning vulnerable residents, he adds, summarizing some of the key recommendations.

Fire hazards in many other high-rise buildings

Following the fire, extensive investigations have revealed that, unfortunately, combustible and inappropriate building materials were also used in thousands of other facade renovation projects in England.

The police will now begin investigating whether there is sufficient evidence to press charges against some of the companies and organizations criticized in the report.

Furthermore, the new Labour Prime Minister, Keir Starmer, has apologized on behalf of the British state and promised to respond to the recommendations within the next six months.

Could the same thing happen in Denmark?

Neither Brian V. Jensen nor Anders Dragsted believe that Denmark is at risk of experiencing a similar catastrophe.

– We have a regulatory system in Denmark with pre-approved solutions that do not allow for a facade construction like the one at Grenfell Tower. We do also use ACM panels in Denmark, but here we use a version with a fire-retardant core, not a combustible one. Additionally, with the Danish Building Regulations (BR18) and the certification scheme, we have a system with far more documentation and oversight of construction, along with high-quality fire safety measures in the higher fire classes, says Brian V. Jensen, though he points out that the certification scheme cannot stand alone:

– Simple and traditional construction can become complex in design and execution, leading to complex fire safety issues when considering the interaction between construction stakeholders, fire safety measures, and the documentation of building materials. Therefore, focus must be placed on the right competencies throughout the construction value chain, he adds and continues:

– In Denmark, we also have a ‘stay put’ strategy in certain buildings. So, one could say that some elements of the Grenfell Tower incident could also happen in Denmark, but not on the same scale due to our level of documentation and oversight.

Although Denmark has a largely well-functioning system, we should still learn from the conclusions of the report, which is based on well-documented and valid evidence.

– In my opinion, in Denmark there is no risk of experiencing a chain of failures of the same magnitude as in London. However, the report’s recommendations are certainly relevant beyond the UK’s borders and can be used in Denmark to raise competencies across the construction sector. There is valuable learning for the Danish construction industry, its stakeholders, and the system we have in Denmark to ensure a robust and transparent system and to build with the necessary safety measures, says Anders Dragsted.

See the report

Read also London fire emphasizes challenges with high-rise buildings

Read also Grenfell Tower Fire Update